Healthcare Provider Details

I. General information

NPI: 1922396399
Provider Name (Legal Business Name): ANJULI S. NAYAK, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 JACOBSSEN DR
NORMAL IL
61761-6280
US

IV. Provider business mailing address

2010 JACOBSSEN DR
NORMAL IL
61761-6280
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-0995
  • Fax: 309-862-0961
Mailing address:
  • Phone: 309-452-0995
  • Fax: 309-862-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MS. RANDE MICHELLE ANDERSON
Title or Position: CREDENTIALING/BILLING
Credential:
Phone: 309-452-0995